How would you improve primary care?

THREE lists of the “top 5” clinical activities that improve patient care while reducing costs in primary care have been compiled by an American doctors’ association.

The National Physicians Alliance (NPA) created the lists of “evidence-based, quality-improving, resource-sparing activities” for family medicine, paediatrics and internal medicine.

The NPA’s suggestions were scrutinised by 83 primary care physicians initially and then by another 172 doctors who rated each activity according to its potential impact on the quality and cost of care, its evidence base and its ease of implementation.

The lists, published in the Archives of Internal Medicine, focus on a less-is-more approach to primary care. (1)

All three lists contain more “don’ts” than “dos”, with an emphasis on cutting out imaging and screening tests in low-risk populations and limiting antibiotic prescribing.

GPs are advised to target the use of lumbar spine imaging for low back pain, Pap smears and antibiotics for acute sinusitis to populations that will receive the most benefit.

The authors write that patient cooperation is required to implement the recommendations, and that they will seek endorsements from consumer groups.

“Having such endorsements will help dispel the misconception that these clinical recommendations represent rationing and support the idea that often less is truly more,” they write.

Top five clinical activities in family medicine:

1. Don’t do imaging for low back pain within the first 6 weeks unless red flags (including severe or progressive neurological deficits) are present

2. Don’t routinely prescribe antibiotics for acute mild to moderate sinusitis unless symptoms (which must include purulent nasal secretions AND maxillary pain or facial or dental tenderness to percussion) last for 7 or more days OR symptoms worsen after initial clinical improvement

3. Don’t order annual ECGs or any other cardiac screening for asymptomatic, low-risk patients

4. Don’ perform Pap tests on patients younger than 21 years or in women status post-hysterectomy for benign disease

5. Don’t use DEXA (dual energy X-ray absorptiometry) screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors (including fractures after age 50)

4 thoughts on “How would you improve primary care?”

Of course your list has important elements in it. However, for me, the first line in saving time while saving lives is ‘get the diagnosis right’. And if there is not a well structured dialogue going on, nothing happens. Or, as your list suggests, what happens doesn’t help.
In Dallas recently at the ’12th Annual International Summit on Improving Patient Care in the Office Practice and the Community’ for IHI (Institute for Healthcare Improvement) I ran 2 x 75 minute workshops for doctors where I was able to demonstrate, in an interactive way, the “dos” of best medical practice in this area.
Knowing how to listen, how to respond, how not to waste time on those ‘kneejerk’ questions, gets you off to a good start. Patients across the world complain – and members of the health professions acknowledge – the crucial role of these connections in correct diagnosis. Then comes support, eg, by nurses and other specialists these patients are supported by, which hastens healing, at its best; but delays it if there is conflict.
And wouldn’t you like to not have so many repeat visits, because you ‘got it right’ the first time? What a saving!
I’m happy to expand on this for those who are truly interested in improving patient care while reducing costs.
It’s so easy, when you’re shown how. (We had a ball in Dallas)
You may give me a call on +61 3 9569 1412
Beryl Shaw

Pay GP enough to encourage physical examination rather than referral to a specialist or super specialist.
Educate and place more GPs in the marketplace.
Pay GP for services where there is non-attendance, eg, repeat prescription. Current bulk-billing encourages unnecessary attendance.
Allow more tablets, eg, 6 months supply, on a single attendance at a pharmacy .. .also means more flexibility in number of tabs prescribed.

1. Don’t treat without checking Cochrane, UptoDate or similare EBM websites and guidelines first.
2. Use some of the millions saved through avoidance of all the above mentioned unneccessary investigations and treatments to make UpToDate and other EBM websites available for free for all doctors (& patients if possible).
3. Use your increased time from ‘getting it right first’ (thanks Beryl for reminding us of the core of our work) for exchange with colleagues and patients to improve our quality of care and quality of life.

Thanks Doc Strange for your acknowledgment. I was so pleased when participants (doctors, nurses, many other top health professionals) responded that, although different from the type of presentation they are used to, the take-away value of the way I get them to work ‘with’ me means they will actually use my ideas in their practice.
And I can’t ask more than that — unless of course it’s that they invite me to visit their hospital or medical practice to extend my quickly learned techniques for all their staff.